Understanding The Stages of
Death and Dying
Dr. BC Farnham & Elizabeth Pugh, LBSW, CM
This program is made possible through a collaborative community-education partnership between The Consortium for Advancements
in Health & Human Services, Inc. and Kindred at Home. The primary goal of this effort is to increase public awareness and access to
hospice and home health through the provision of community-based education. Contact Hours are awarded to professionals who
complete this program by The Consortium for Advancements in Health & Human Services, Inc. (www.cahhs-partners.org)
The Consortium for Advancements in Health and Human Services, Inc. © 2014
Important Information

This education program for healthcare professionals was developed by The Consortium for Advancements in
Health and Human Services, Inc. (CAHHS) and is facilitated by Kindred Hospice via a community education
partnership agreement. CAHHS is a private corporation and is solely responsible for the development,
implementation and evaluation of its educational programs. There is no fee associated with receiving contact
hours for participating in this program titled, Understanding the Stages of Death and Dying. However,
participants wishing to receive contact hours must offer a signature on the sign-in sheet, attend the entire
program and complete a program evaluation form.

The Consortium for Advancements in Health and Human Services, Inc. is an approved provider of continuing
nursing education by the Alabama State Nurses Association, an accredited approver by the American Nurses
Credentialing Center's Commission on Accreditation.

The Consortium for Advancements in Health & Human Services, Inc., is approved as a provider of c ontinuing
education in Social Work by the Alabama Board of Social Work Examiners, #0356, Expiration
Date: 10/31/2016.

This program is Approved by the National Association of Social Workers (Approval #886684291-5176) for 1Pain/Symptom Management continuing education contact hour.

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
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Learning Objectives
 Discuss the various psychosocial tasks associated
with the final days of life.
 Identify the five stages of dying as outlined by
Kubler-Ross.
 Discuss patient behaviors associated with each of
the five stages of dying as outlined by Kubler-Ross.
 Discuss how healthcare professionals and family
members can help patients experiencing the five
stages of dying as outlined by Kubler-Ross.
 Identify benefits of hospice care that support
patients facing a terminal illness.
The Final Days of Life
 Significant for many patients, because they use
this time to say goodbye, resolve unfinished
business and to complete the various
developmental tasks associated with the end-oflife.
The Final Days of Life
 In order for patients to realize the power of the
hospice benefit, professionals must be
comfortable with talking about death and dying
with patients and their loved ones.
 Professionals must offer empathy, education, and
compassion, while demonstrating unconditional
positive regard and sincerity.
The Final Days of Life
 During the final moments of life, a hospice
professional must be comfortable with the idea
of “being there” for patients and their family
members. There is tremendous power in
presence.
 The entire interdisciplinary team is involved in
caring for the dying patient and their family. All
team members work closely with one another to
provide individualized care to the patient and
their family members, as the needs of each
patient and family are different.
Five Stages of Dying:
Kubbler-Ross
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
Denial
 “This can’t be happening to me…”
 The patient denies the realities and terminality of an illness.
 Patients may appear “emotionally shocked.”
 Denial is a natural defense mechanism that enables a person
to monetarily escape the anxiety or emotional reactivity
associated with a life circumstance.
 Denial enables one to gain the time needed to frame or
compartmentalize the initial reactions to “bad news.”
Denial continued
 Patient Behavior
 Questions the validity of lab tests, changes doctors,
attributes symptoms to less threatening conditions
or diseases.
 Patients may accept a diagnosis, but believe he/she
is going to beat the odds through aggressive
treatment.
Denial continued
 How to help:
 Respect the patient’s natural defense mechanism.
 Be aware of your own behavior affecting the
patient’s openness.
 After a patient has employed denial for a reasonable
amount of time, it is appropriate to start reframing
dialogue in a manner that gentle explores “What
if…” or “I would feel…” statements.
Anger
 “Why is this happening to me?”
 This is a reflex-based and self-protective
response to fear and pain. A patient is angry
because of a perceived unfairness that God
and/or fate has singled him/her out for illness,
while others are able to remain healthy, functional
and free from the terminality of an illness.
Anger continued
 Patient behavior:
 May be impatient, restless, rude, hypersensitive,
unappreciative, combative or overly demanding.
 The patient may demonstrate a cycle of behaviors
that center on isolation-attack behaviors.
 Patients may be combative or attacking of God,
clergy and/or religion.
Anger continued
 How to help:
 Embrace the patient’s anger and recognize it is a
natural process.
 Be supportive and understanding of the patient’s need
to act out and to be vocal about feelings.
 Attempt to communicate about the patient’s feelings
of anger and hostility, as the emotions are likely
rooted in fear.
 Avoid dialogue that dismisses the patients feelings, as
being “Pollyanna” will not make things better. Feelings
must be felt and explored.
Bargaining
 “This is happening to me, but…”
 Patients will often attempt to delay death by
bargaining with God or with healthcare
professionals, which may involve making
promises in exchange for more time.
 “If you do this… I will do that.”
Bargaining continued
 Patient Behaviors:
 Engages in dialogue that is attempting to negotiate
prognosis of the illness.
 Bargaining Statements will be something like this,
“If I can make it to her wedding date” or “I will be
ready to go once I have seen him graduate from
college.”
Bargaining continued
 How to help:
 Recognize and respect the persons need to bargain,
as it is a key aspect of preparing for the end of life.
 Help the person focus on attainable goals that are
immediate, as time is never guaranteed to any of us.
 Avoid talking in terms of time and help the person
focus on outcomes or achievements that can be
realized.
Depression
 “Oh no… it is me”
 The patient experiences full realization that
he/she is going to reach the end of life and die.
Depression is a symptom and a defense
mechanism that prepares the patient for the
magnitude of the impending loss of life.
Depression continued
 Patient Behavior:
 May be tearful, self isolate, withdraw from family
and friends, dwell on past failures or future losses.
 May be restless and have a loss of appetite.
 Patient my have radical changes in sleep patterns.
Depression continued
 How to help:
 Let the patient know its okay to cry and to
experience the loss.
 Provide presence and increase social/emotional
support.
 Help patient find spiritual peace if appropriate and
consistent with patient’s belief system.
 Support patient as he/she works through various
tasks associated with finding closure and saying
goodbye to significant others.
Acceptance
 “I am ready.”
 Acceptance is not marked by bitter resignation or
tremendous joy, as it is a peaceful acceptance of
one’s fate. Often patients will express a desire to
reach an end of their suffering or the suffering of
others.
Acceptance continued
 Patient Behaviors:
 Sense of peace and “letting go” or “giving it all up
to God.”
 Peaceful balance with regard to emotional status.
 Focus shifts to the immediate, and sometimes
patients narrow the social support systems to only
include immediate family and very close friends.

 Patients may elect to disengage with family
members.
Acceptance continued
 How to help:
 Take time to foster meaningful communication and
socialization, if the patient is able and desires to
speak or socialize.
 Shift social supports to the family and close friends,
as they will need to support and to address
anticipatory grief and their impending loss.
 Be present, responsive and available.
Dying is an Individualized
Experience
•
There is no such thing as a---typical death.
•
Each person dies in their own way, own time, and with their own culture,
belief system, values and unique relationships with others.
•
When patients are aware of their approaching death, they often know where
they want to die and with whom they want to die.
•
Healthcare professionals need to advocate for patient/family choices related
to death and dying--specifically to where they wish to die, who they wish to
be present and accessing effective pain and symptom management through
hospice.
The Benefits of Hospice Care
 Patients and their family members can benefit from the
expertise of an interdisciplinary team, which address the
physical, emotional and spiritual aspects of the end of life.
 Patients and families are offered effective pain and symptom
management, which improves the quality of life.
 Patients and their family members are afforded educational
supports that decrease the anxiety associated with a terminal
illness.
 Patients and their family members are afforded choice about
where they die, and “home” becomes a viable option.
The Benefits of Hospice Care
continued
•
Access to healthcare specialist 24/7.
•
Ongoing emotional support and counseling services are available.
•
Bereavement services are provided to the entire family throughout the course
of the illness and for 13 months following the death of a patient.
•
Patients and family members are not alone in their journey, as they are
supported by nurses, social workers, chaplains, bereavement counselors,
hospice aides and volunteers.
How Can You Help?

Offer hospice services to your patients and their family members.

Encourage people you know personally who are facing a terminal illness to explore
hospice and to learn more about the services provided.

Talk about death and dying to determine what services and supports are needed.

Volunteer with a hospice program.

Remember, hospice care is about improving quality of life and most hospice patients
state they wish they had received services sooner.

Recognize and respect the various natural stages associated with the end of life.

Never underestimate the power of presence or a compassionate shoulder… be there
for people during the end of life.
References
 The stages of grief. (n.d.). Retrieved July 16, 2010 from
Memorial Hospital website:
http://www.memorialhospital.org/library/general/stress-the3.html
 What are the stages of grief. (n.d.). Retrieved July 16, 2010 from
Cancer Survivors.orgwebsite:
http://www.cancersurvivors.org/Coping/end%20term/sta
ges.htm
 Wang_Cheng, B. (2002). Fast fact and concept: Dealing with
anger. Retrieved July 16, 2010 from End of Life/Palliative
Education Resource Center website: http://
www.mywhatever.com/cifwriter/library/eperc/fastfact/
ff59.html
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